This case involves a woman with extensive oesophageal varices due to alcoholic liver disease. She presented to us with recurrent oesophageal bleeding which required several (about six) sclerotherapy sessions to stop the bleeding. Due to several sclerotherapy sessions, it was difficult to band the varices as the oesophageal wall was oozing blood without clear varices to band. One month later, she became ill with high grade fever. Chest x ray (fig 1) showed obliteration of the right costophrenic angle and an empyema-like picture with fluid level. Aspirations of the pleural fluid/pus were unsuccessful. She had an ultrasound guided chest drainage which drained puss mixed with food particles. Despite using various courses of antibiotics, her fever and empyema were relentless. To investigate the cause of her persistent empyema, a computed tomography (CT) scan with water soluble contrast was done. The CT scan (fig 2) showed a perforation in the right side of the distal oesophagus into the pleural space which contained a large volume of gas, contrast, and food debris. There was a collapse of the adjacent right lower lobe. The patient was referred to a cardiothoracic centre for repair of the oesophagopleural fistula.

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Figure 1

Chest x ray showing obliteration of the right costophrenic angle and empyema (upper arrow). There is also a radio-opaque shadow in the stomach (lower arrow) which is due to previous sclerotherapy for gastric varices.

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Figure 2

Computed tomography scan with perforation in the right side of the distal oesophagus into the pleural space which contained a large volume of gas, contrast, and food debris.

Oesophageal perforation is a serious complication of therapeutic upper gastrointestinal (GI) endoscopy.1 Pleural effusion after upper GI endoscopy should alert the physician to seek an underlying cause, especially if it is resistant to treatment.1 Oesophageal perforation may not present acutely but may present later on with oesophagopleural fistula, as in this case.2